Maternal psychiatric illness can profoundly affect how a mother interacts with her child and is a risk factor for impaired mother-infant bonding, which may include a spectrum of difficulties: decreased maternal affective involvement, increased irritability, aggressive impulses, or, at worst, outright rejection of the infant (Brockington et al, 2006).  It is important to note, however, that not all women with postpartum psychiatric illness experience impaired bonding.  A new study from Women & Infants Hospital of Rhode Island has assessed mother-infant bonding in a group of180 postpartum woman and has identified several factors which were predictive of impaired bonding.

This was a group of 180 women treated in a psychiatric partial hospitalization program.  Medical records were reviewed, and the following information was gathered: information on demographic variables (age, race/ethnicity, number of weeks postpartum, number of children at home), information about the pregnancy and delivery (e.g., mode of delivery, delivery complications), and clinician-rated diagnoses.  Bonding was measured using the self-rated Postpartum Bonding Questionnaire (PBQ).  Depressive symptoms were assessed using the Edinburgh Postpartum Depression Scale (EPDS).

In this cohort, the most common diagnosis was a major depressive disorder (MDD) (77 %). Over one-fourth (29 %) of patients received a diagnosis of an anxiety disorder.  Consistent with previous research, this study indicated that one of the strongest predictors of impaired mother-infant bonding was the severity of maternal depressive symptoms. In addition, women with self-reported suicidality reported greater impairment on three of four PBQ subscales.

Interestingly, women who gave birth via Caesarean reported higher levels of rejection/pathological anger compared to women who delivered vaginally. The authors speculate that although most women experience no adverse outcomes following C-section delivery, bonding may be disrupted because, in comparison to women who deliver vaginally, mothers who deliver via Caesarean section are significantly less likely to breastfeed and often have a delay in first interaction with their infants.

Another unexpected finding was that Caucasian women reported significantly higher levels of maternal anxiety compared to non-Caucasian women. Only one prior study assessed for racial/ethnic differences in mother-infant bonding (Loh and Vostanis, 2004) but found no racial/ethnic differences.

The next step is determining how to improve bonding in these women at high risk for bonding difficulties.  This is a very interesting area of research.  In addition to psychotherapy and pharmacologic treatment which target the depressive symptoms, there is probably a role for other interventions that enhance bonding.  In a randomized control trial of 117 depressed mothers, Horowitz and colleagues demonstrated that 8 weeks of interaction coaching significantly improved mother–infant interactions.

There is also the very interesting work coming out of Tiffany Field’s group.  Interaction coaching has been developed to help mothers improve their interactions with their babies by providing video feedback and giving them second-by-second suggestions as interactions occur (see Field 2006). These interventions have been shown to be effective in reducing depressive symptoms in the mother and improving the quality of interactions between the mother and her infant. Field has also demonstrated that teaching depressed mothers to massage their infants has resulted in less irritability and fewer sleep problems in the infants and better mother-infant interactions, as well as a reduction in the mothers’ depressive symptoms (Goldstein-Ferber, 2004).

Ruta Nonacs, MD PhD

Brockington IF, Aucamp HM, Fraser C (2006) Severe disorders of the mother-infant relationship: definitions and frequency. Arch Women’s Mental Health 9:243–251.

Sockol LE, Battle CL, Howard M, Davis T.  Correlates of impaired mother-infant bonding in a partial hospital program for perinatal women.  Arch Womens Ment Health. 2014 Oct;17(5):465-9.